Dr. Smith's ECG Blog

DECEMBER 11, 2023

What would you do at this time with this information? But pain is an important signal in MI and informs the clinician of the urgency. For the same reason, you should not delay coronary angiography because pain resolves with morphine. But pain is a critical signal for urgency in the context of acute coronary syndrome.

E-9-1-1 123

E-9-1-1 Coronary ACS STEMI 123

ALiEM

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. View other cases from this Clinical Image Series on ALiEM.

Plasma 161

Plasma Coronary Emergency Department OR 161

Dr. Smith's ECG Blog

MAY 10, 2023

At this point, with the information above, the patient's overall clinical picture could be consistent with either reperfused OMI, or Non-OMI, since both may have absent pain and inverted T waves. A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. But STEMI criteria is only 43% sensitive for OMI.[1] De Alencar Neto.

STEMI 120

STEMI Coronary ALS Emergency Department 120

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI".

Defibrillator 131

Defibrillator Coronary STEMI CPR 131

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. This included the addition several new STEMI equivalents [4] on ECG that warrant “prompt evaluation for emergency coronary angiography.”

STEMI 111

STEMI Coronary Emergency Department OR 111

The Skeptics' Guide to EM

MAY 19, 2018

Listen to the podcast on iTunes to hear Dr. Kline discuss some background information on the diagnosing of pulmonary embolism and the PERC Rule. * The eight-items include the following clinical criteria. If the answer to any of these questions is positive a d-dimer is indicated.

Emergency Department 130

Emergency Department ALS Coronary OR 130

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. I sent both ECGs to Dr. Smith, with the only information that these were prior vs new ECG.

STEMI 89

STEMI Coronary OR ED 89

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. If so, how will they change management?

STEMI 112

STEMI ACS Coronary OR 112

Dr. Smith's ECG Blog

JUNE 17, 2024

If this EKG were handed to you to screen from triage without any clinical information, what would you think? Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. What do you think? In fact, Kosuge et al. Accessed May 28, 2024.

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

Dr. Smith's ECG Blog

OCTOBER 12, 2023

Accompanying the ECGs is some clinical information. Look at the ECGs and consider the timeline and other information. Would you change you interpretation if the following information was added? B elow are 4 ECGs from the same patient. At the bottom will be five alternative clinical scenarios to explain the findings.

Coronary 103

Coronary OR ED 103

Dr. Smith's ECG Blog

OCTOBER 3, 2024

This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. Coronaries were clean. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. I assumed it was a patient with acute chest pain. What do you think, Steve? Real or just fake?"

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

Dr. Smith's ECG Blog

DECEMBER 9, 2023

I read this blinded, with no clinical information, and read it as inferior OMI. The Queen of Hearts interprets it blinded also (no clinical information and no previous ECGs or serial ECGs). A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA.

STEMI 107

STEMI Coronary ED Paramedic 107

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. Janssens, G.

Coronary 72

Coronary CPR OR ICU 72

Dr. Smith's ECG Blog

JUNE 15, 2023

Written by Pendell Meyers Both of these cases were sent to me with no information other than adults with acute chest pain. What would be your response? Case 1: Case 2: What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? Case 1 An elderly male presented with chest pain.

STEMI 90

STEMI Coronary ACS OR 90

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion.

STEMI 102

STEMI Coronary ACS ED 102

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. The patient is a 75-year old man with known coronary disease, including prior LAD and LCx OMI. That this patient has severe underlying coronary disease is indisputable.

OR 106

OR STEMI Coronary ED 106

The Skeptics' Guide to EM

JANUARY 22, 2020

As crude measures they fail to incorporate any other information into their estimates, including potential confounders for the relationship between the test result and the outcome.

Coronary 100

Coronary OR 100

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed all results with patient.

Coronary 75

Coronary STEMI EMS OR 75

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

This ECG was texted to me with no other information. I assumed the presentation was consistent with acute MI. What did I say? Activate the cath lab." The T-waves in V2-V6 are diagnostic. It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. There is also some non-diagnostic STE in inferior leads.

OR 124

OR STEMI Coronary 124

Dr. Smith's ECG Blog

JANUARY 9, 2023

This was sent to me with no information and I immediately replied that it was diagnostic of LAD OMI. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

DECEMBER 3, 2024

Smith : this was shown to me without any other information, and I said that it is strongly suggestive of inferior OMI, probably reperfused. Given his history, an EKG, labs including high sensitivity troponin, and chest radiograph were ordered. Here is the first ECG at Time zero: Here is his initial EKG: What do you think?

ED 96

ED Coronary ACS STEMI 96

Dr. Smith's ECG Blog

OCTOBER 18, 2023

I sent the top ECG to Dr Smith with no information and without the baseline ECG. The patient was referred for coronary angiography which did not reveal any atherosclerotic changes. A formal echo at the PCI center after coronary angiography revealed a large septal and apical WMA. The chest pain quickly subsided.

Defibrillator 105

Defibrillator Advanced Life Support Coronary Life Support 105

Dr. Smith's ECG Blog

MAY 23, 2023

The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. EMS arrived and recorded this ECG: What do you think?

STEMI 86

STEMI Coronary Paramedic OR 86

Dr. Smith's ECG Blog

MARCH 13, 2024

Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality ( e.g. sepsis). High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref. <

Coronary 87

Coronary ACS Emergency Management Emergency Manager 87

EMDocs

SEPTEMBER 15, 2023

ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia Source Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. Ann Emerg Med. 2023 Aug;82(2):219-221.

Emergency Medical Services 61

Emergency Medical Services Coronary Emergency Department EMS 61

Dr. Smith's ECG Blog

AUGUST 9, 2024

Learning points: Both patients and other medical providers can report confusing and often contradictory information that obfuscates the diagnosis (in this case, WPW). Serial ECGs enhance the diagnosis of acute coronary syndrome. If the story and ECG findings are concerning, use your clinical judgment to advocate for PCI. Washam, J.

STEMI 86

STEMI Coronary Heart Attack ACS 86

Dr. Smith's ECG Blog

JULY 2, 2023

Outcome The only followup we got was that the patient is undergoing Coronary Bypass (CABG) of LAD, 2nd Obtuse Marginal, and Left Posterolateral coronaries. We don't know if he had a stress test, a CT Coronary angiogram, or they just decided to do an angiogram. Thus, Unstable Angina. I’m not sure if you know who the queen is.

ACS 52

ACS Coronary OR 52

ECG & Echo Learning

OCTOBER 28, 2023

Table 1 provides a summary of the indications, contraindications, dosage, administration, warnings, precautions, and other relevant information for the drug Prasugrel. – For UA/NSTEMI patients undergoing coronary angiography within 48 hours, the dose should be given at the time of PCI. – Active bleeding.

Coronary 52

Coronary OR 52

Dr. Smith's ECG Blog

JULY 31, 2018

I saw this before any other information and knew immediately that it represented an LAD occlusion. Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection. There is 1 mm of STE in lead V2.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. The ECG shows slight ST Elevation in an inferolateral distribution. Notice how QOH is not fooled by this ST-Elevation.

Coronary 84

Coronary OR STEMI EMS 84

EMDocs

SEPTEMBER 26, 2024

Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. If you have a story to share click here. Who is responsible for notifying patients of post discharge findings?

Emergency Department 75

Emergency Department ED Coronary ALS 75

OntarioMedic

FEBRUARY 8, 2018

In this category, most cases are a result of end-stage coronary artery disease, either with a history of myocardial infarction or with a chronically underperfused, yet viable, myocardium. Q waves in contiguous leads strongly implicate a previous myocardial infarction and coronary artery disease as the cause. Currently, 5.7

Coronary 52

Coronary CAD OR 52

EM Literature of Note

OCTOBER 18, 2021

Pervasive use of CT coronary angiography has been an unnecessary feature of the evaluation of patient with low-risk chest pain for the better part of a decade now. Patients were eligible by symptoms of an acute coronary syndrome, supported by ECG changes, an elevated troponin, or a history of ischemic heart disease.

Coronary 40

Coronary CAD ED OR 40

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. Incidence of an acute coronary occlusion. Incidence of an Acute Coronary Occlusion. link] Harhash AA et al.

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

JUNE 11, 2011

All coronaries were completely normal. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Additionally, appropriate discordance is common in NonSTEMI, but very unusual in coronary occlusion (STEMI). Is this an anterior STEMI with LBBB? He was taken to the cath lab. link] Shvilkin et al.

STEMI 52

STEMI Coronary ALS ED 52